The association between county-level premature cardiovascular mortality related to cardio-kidney-metabolic disease and the social determinants of health in the US

Abstract

Cardio-kidney-metabolic (CKM) syndrome is defined by the American Heart Association as the intersection between metabolic, renal and cardiovascular disease. Understanding the contemporary estimates of CKM related mortality and recent trends in the US is essential for developing targeted public interventions. We collected state-level and county-level CKM-associated age-adjusted premature cardiovascular mortality (aaCVM) (2010-2019) rates from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER). We linked the county-level aaCVM with a multi-component social deprivation metric: the Social Deprivation Index (SDI: range 0-100) and grouped them as follows: I: 0-25, II: 26-50, III: 51-75, and IV: 76-100. We conducted pair-wise comparison of aaCVM between SDI groups with the multiplicity adjusted Wilcoxon test; we compared aaCVM in men versus women, metropolitan versus nonmetropolitan counties, and non-hispanic white versus non-hispanic black residents. In 3101 analyzed counties in the US, the median CKM associated aaCVM was 61 [interquartile range (IQR): 45, 82]/100 000. Mississippi (99/100 000) and Minnesota (33/100 000) had the highest and lowest values respectively. CKM associated aaMR increased across SDI groups [I - 45 (IQR: 36, 55)/100 000, II- 61 (IQR: 49, 77)/100 000, III- 77 (IQR: 61, 94)/100 000, IV- 89 (IQR: 70, 110)/100 000; all pair-wise p-values < 0.001]. Men had higher rates [85 (64, 91)/100 000] than women [41 (28, 58)/100 000](p-value < 0.001), metropolitan counties [54 (40, 72)/100 000] had lower rates than non-metropolitan counties [66 (49, 90)/100 000](p-value < 0.001), and non-Hispanic Black [110 (86, 137)/100 000] had higher aaMR than non-Hispanic White residents [59 (44, 78)/100 000](p-value < 0.001). In the US, CKM mortality remains high and disproportionately occurs in more socially deprived counties and non-metropolitan counties. Our inability to reduce CKM mortality rates over the study period highlights the need for targeted policy interventions to curb the ongoing high burden.

Keywords: Cardiometabolic health; Cardiovascular disease; Diabetes; Kidney disease; Obesity; Renal failure.

Fig. 1

Social deprivation index across US counties. This map presents the SDI group that each US county in our study belongs to. The counties that are excluded in our study have been grayed out. Abbreviation: SDI – social deprivation index

Fig. 2

Title: County-level CKM related premature age adjusted cardiovascular mortality in the US. (A) This map presents the county-level median CKM related premature aaCVM rate reported in each county that we studied. (B) This grouped boxplot presents the distribution of the CKM related premature aaCVM rates for each SDI group. The middle of each boxplot notch corresponds to the median value, the lower and upper ends of the box correspond to the 1st and 3rd quartile, and the lines extend to include 1½ times the interquartile range at each end of the distribution.

Fig. 3

County-level CKM related premature age adjusted cardiovascular mortality in the US according to the SDI according to sex, location, and race. These grouped boxplots report CKM related aaCVM rates according to the SDI groups for (A) men and women, (B) metropolitan and non-metropolitan counties, and (C) non-Hispanic White and non-Hispanic Black residents. The middle of each boxplot notch corresponds to the median value, the lower and upper ends of the box correspond to the 1st and 3rd quartile, and the lines extend to include 1½ times the interquartile range at each end of the distribution. Abbreviations: aaCVM – age adjusted cardiovascular mortality, CKM – cardio-kidney-metabolic syndrome, SDI – social deprivation index

Fig. 4

US counties that reported median CKM related premature age adjusted cardiovascular mortality rates above the national rate. In this maps panel, counties that reported median CKM related aaCVM rates above the national rate are colored red while the others are colored green. Counties not included in the analysis are grayed out in each map.